Consumer Fraud Complaint - Sacramento County District Attorney

CONSUMER AND ENVIRONMENTAL PROTECTION DIVISION
SACRAMENTO COUNTY DISTRICT ATTORNEY
906 G Street, Suite 700
(0Sacramento,
Sacramento,CA
CA914www.da.saccounty.net
95814
Phone: (916) 874-6174 Fax: (916) 321-2232
Anne
Anne Marie Schubert
0
0
FOR OFFICE USE ONLY
FILE NUMBER
OPEN
REFER
ASSIGNED TO
www.sacda.org
District Attorney
CAO DA 1
CONSUMER FRAUD COMPLAINT FORM
I understand that the Sacramento County District Attorney is not permitted to take action in order to
obtain money owed to me, to help cancel any debt due on a contract I signed, or obtain any other
personal relief for me. If the District Attorney determines to file a criminal and/or civil action in this matter,
I understand that such action will not result in the obtaining of money or other personal relief
for me. I also understand that the filing of this complaint does not prevent me from filing a private lawsuit
with or without the aid of a private attorney or seeking restitution in Small Claims Court. I am filing this
complaint with the Sacramento County District Attorney for the purpose of bringing this matter to their
attention for review and any further action they may determine to be appropriate.
NAME (LAST, FIRST, MIDDLE):
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DATE OF BIRTH:
E-MAIL ADDRESS:
HOME ADDRESS (STREET):
BUSINESS ADDRESS (STREET):
(CITY, STATE ZIP CODE):
(CITY, STATE ZIP CODE):
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PHONE NUMBER (HOME):
PHONE NUMBER (BUSINESS):
PHONE NUMBER (ALTERNATE):
D I wish to file a complaint against the company/individual named below. I understand that the District Attorney's
Consumer and Environmental Protection Unit is unable to represent private citizens seeking the return of
their money or other personal remedies.
NAME OF COMPANY, FIRM, OR INDIVIDUAL:
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BUSINESS ADDRESS (STREET):
SALESPERSON NAME (IF ANY):
(CITY, STATE ZIP CODE):
PHONE NUMBER (BUSINESS):
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TYPE OF BUSINESS OR SERVICE
D ADVERTISED ITEM NOT AVAILABLE (IF CHECKED, PLEASE ATTACH COPY OF ADVERTISEMENT)
D ORAL MISREPRESENTATION
D DEFECTIVE MERCHANDISE
D GUARANTEE OF CONTRACT NOT FUFILLED D NON-DELIVERY OF MERCHANDISE
D MISREPRESENTATION OF ADVERTISMENT
D PROMISED ADJUSTMENT NOT FULFILLED
D UNSATISFACTORY INSTALLATION OR SERVICE D OTHER (DESCRIBE BELOW)
I
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CONSUMER AND ENVIRONMENTAL PROTECTION DIVISION
SACRAMENTO COUNTY DISTRICT ATTORNEY
SUMMARY OF COMPLAINT
DATE OF TRANSACTION/INCIDENT:
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TOTAL LOSS:
LOCATION OF TRANSACTIONIINCIDENT (ADDRESS, CITY, STATE):
AT BUSINESS
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D VIA TELEPHONE i
NAME OF PRODUCT OR SERVICE INVOLVED
HAS THERE BEEN AN ATTEMPT TO RESOLVE THE PROBLEM?
HAS A CONTRACT OR WARRANTY BEEN SIGNED?
HAVE YOU FILED IN SMALL CLAIMS COURT?
STATE AND COUNTY OF WHERE CASE FILED:
D NO D YES (INCLUDE DETAILS IN NARRATIVE)
D NO D YES (INCLUDE A COPY OF THE PAPERWORK)
D NO D YES (COMPLETE THE FOLLOWING)
STATUS/RESUL T:
CASE/FILE NUMBER:
DATE OF FILING:
D NO D YES (COMPLETE THE FOLLOWING)
HAVE YOU CONTACTED AN ATTORNEY?
NAME OF ATTORNEY:
PHONE NUMBER (BUSINESS):
BUSINESS ADDRESS (STREET):
STATUS/RESUL T:
(CITY, STATE ZIP CODE):
HAVE YOU FILED A COMPLAINT WITH ANOTHER AGENCY?
NAME OF AGENCY:
DATE OF COMPLAINT:
STATUS/RESUL T:
i CASE/FILE NUMBER:
D NO D YES (COMPLETE THE FOLLOWING)
DO YOU KNOW OF ANY ADDITIONAL WITNESSES?
NAME OF FIRST WITNESS:
D NO D YES (COMPLETE THE FOLLOWING)
PHONE NUMBER (HOME, CELL, OR BUSINESS):
HOME ADDRESS (STREET):
ADDITIONAL ADDRESS (STREET):
(CITY, STATE ZIP CODE):
(CITY, STATE ZIP CODE):
NAME OF SECOND WITNESS:
PHONE NUMBER (HOME, CELL, OR BUSINESS):
HOME ADDRESS (STREET):
ADDITIONAL ADDRESS (STREET):
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(CITY, STATE ZIP CODE):
(CITY, STATE ZIP CODE):
D CHECK IF ADDITIONAL AGENCIES WERE CONTACTED OR THERE ARE ADDITIONAL WITNESSES (INCLUDE IN NARRATIVE OF EVENTS)
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CONSUMER AND ENVIRONMENTAL PROTECTION DIVISION
SACRAMENTO COUNTY DISTRICT ATTORNEY
NARRATIVE OF EVENTS
PLEASE DESCRIBE FULLY WHAT OCCURRED. DESCRIBE THE EVENTS IN THE ORDER THEY HAPPENED. IF NECESSARY,
USE ADDITIONAL SHEETS OF PAPER AND SUBMIT THEM WITH THIS FORM.
ADDITIONALLY, PLEASE ATTACH COPIES (SUBMITTED ITEMS WILL NOT BE RETURNED) OF ALL ADVERTISEMENTS,
BILLS, RECEIPTS, CONTRACTS, WARRANTIES OR DOCUMENTS IMPORTANT TO THIS MATTER.
D I understand that a copy of this complaint may be mailed to the party complained against unless I state, in writing, why
it should not be sent
THE INFORMATION CONTAINED IN THIS COMPLAINT FORM IS TRUE, CORRECT AND COMPLETE TO
THE BEST OF MY KNOWLEDGE.
SIGNATURE OF COMPLAINANT
REV 10/2007
DATE SIGNED
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SDA CEPD CFCF # 1